Flex Plan + One Enrollment Please enable JavaScript in your browser to complete this form.In which market are you enrolling? *BrentwoodMurfreesboroPrimary Member Name *FirstLastEmail *Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWho else will be on the Flex +1 Plan with you?Spouse/Significant OtherChildParentAdditional Flex +1 Members must have the same residential address as the primary member to qualify.Additional Member Name *FirstLastAdditional Member Email *Additional Member PhoneFlex Plan +1 Monthly Recurring Membership *Price: $ 90.00I agree to annual enrollment with IMAC Regeneration Center for supportive wellness care described above. I acknowledge and understand that my agreement to the fees listed is based on annual assessment of pricing. My annual fee is non-refundable and is not dependent on cancellation of any or all services. Annual Membership Fee will be due at time of initial examination.Credit Card Details *CardName on CardMessageSign Me Up! Committed to People, Committed to your Future. BOOK APPOINTMENT
